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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006317
Report Date: 08/08/2023
Date Signed: 08/08/2023 04:40:41 PM

Document Has Been Signed on 08/08/2023 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:FAITHFUL HOME OF ROSSMOOR, AFACILITY NUMBER:
306006317
ADMINISTRATOR:MUNROE, ALICIAFACILITY TYPE:
740
ADDRESS:2851 BOSTONIAN DRTELEPHONE:
(714) 300-8055
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY: 6CENSUS: 5DATE:
08/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Theresa Kholoma, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of documenting a deficiency observed during the investigation of complaint 22-AS-20230804111101 at the facility. LPA had been greeted and granted entry by facility staff after introducing himself and the reason for the visit. Administrator Theresa Kholoma was notified by telephone and arrived later to assist with the visit. LPA went over the deficiency observed and provided a consultation on resident records as three recent admission agreements were observed to be missing an administrator signature.

One Type B deficiency is cited on the attached form LIC809-D. A Technical Assistance Advisory Note is also issued regarding the Admission Agreements.

An exit interview was conducted and a copy of this report along with appeal rights were provided to facility representative via email due to printer technical difficulties.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2023 04:40 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 08/08/2023 at 04:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: FAITHFUL HOME OF ROSSMOOR, A
FACILITY NUMBER: 306006317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2023
Section Cited
CCR
87608(a)(5)(B)

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The California Code of Regulations Section 87608(a)(5)(B) on Postural Supports states: "(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care(...)." This requirement is not met as evidenced by:
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Licensee stated the bed rails had been equipped on the hospital bed when it was delivered at the facility, however resident does not actually need bedside postural support. The full rails were removed during the visit. Citation cleared during the visit.
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Based on observation and interview, full rails were shown to be equipped on the bed of resident R1, who is not receiving hospice care at the time of the visit. This constitutes a potential risk to the health, safety and personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
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